A list of the most recent deficiencies for Regency Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-14 | 2023-11-28 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-14 | 2023-11-28 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-08-03 | 2023-08-09 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-04 | 2023-06-02 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-05-04 | 2023-05-18 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-05-04 | 2023-05-18 | N |
| Develop a communication plan. | Fire Safety | 2023-05-04 | 2023-05-18 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-05-04 | 2023-05-18 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-05-04 | 2023-05-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-04 | 2023-05-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-04 | 2023-05-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-20 | 2023-05-11 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-20 | 2023-05-11 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-20 | 2023-05-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-20 | 2023-05-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-04-20 | 2023-05-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-20 | 2023-05-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-04 | 2023-05-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-05-04 | 2023-05-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-05-04 | 2023-05-11 | N |
| Have exits that are accessible at all times. | Fire Safety | 2023-05-04 | 2023-05-10 | N |
| Ensure operating rooms are properly protected and written records are maintained and available for inspection. | Fire Safety | 2023-05-04 | 2023-05-10 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-02-16 | 2023-03-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-16 | 2023-03-06 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2023-02-16 | 2023-03-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-11 | 2022-09-09 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-06 | 2022-05-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-06 | 2022-05-09 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-05-06 | 2022-05-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-06 | 2022-05-06 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-03-31 | 2022-04-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-03-31 | 2022-04-15 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-03-31 | 2022-04-15 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-03-31 | 2022-04-15 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-03-31 | 2022-04-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-31 | 2022-04-15 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-20 | 2021-09-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-20 | 2021-09-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-20 | 2021-09-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-08-20 | 2021-09-21 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-29 | 2021-05-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-04-29 | 2021-05-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-05-05 | 2021-05-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-04-29 | 2021-04-29 | N |
